Value PPO Plan

With this option, you have the flexibility to see providers who meet yours or your family’s health care needs. “PPO” refers to “preferred provider organization” – an important feature of this type of medical plan.

Here’s how it works:

The Value PPO option has two level of benefits: Network and Non-network. Each time you need care you decide whether to see a network or non-network provider. You receive higher benefits when you see network providers. Network providers will also file claims for you. To see a list of network providers for your area, sign on to www.myuhc.com.   

Deductible applies to all network and non-network services except where noted. 
Summary of Benefits Network Provider Non-Network Provider

Physician Services

    Primary Care Physicians

    Specialists 

 

$25 Co-payment

$35 Co-payment

(Deductible does not apply)

 

50% of MNRP*

Preventive Care

100%

(Deductible does not apply)

Not-covered

Well Baby Care

100%

(Deductible does not apply)

Not-covered

Hospital Inpatient

80%

50% of MNRP*

Hospital Outpatient

80%

50% of MNRP*

Emergency Room

80% after $90 co-pay for emergencies (deductible does not apply)
 (co-payment is not waived even if admitted)

80% after $140 co-pay for non-emergencies (deductible applies)

(co-payment is not waived even if admitted)

80% of MNRP* after $90 co-pay for emergencies (deductible does not apply)

(co-payment is not waived even if admitted)


50% of MNRP* after $140 co-pay for non-emergencies (deductible applies)

(co-payment is not waived even if admitted)

Urgent Care Centers

$35 Co-payment

(Deductible does not apply)

50% MNRP*

Surgery

80%

50% MNRP*

X-ray & laboratory

80%

50% MNRP*

Prescription Drugs

(one month supply)

Tier 1:  90% ($15 min/$25 max)

Tier 2:  80% ($30 min/$55 max)

Tier 3:  60% ($60 min/ $85 max)

(Deductible does not apply) 

Not covered

Mail Order Prescription

(3 month Supply)

Tier 1:  90% ($25 min/$45 max)

Tier 2:  80% ($60 min/$110 max)

Tier 3:  60% ($120min/$170 max)

(Deductible does not apply) 

Not covered

Mental Health & Chemical Dependency

Inpatient 80%

Outpatient 80% after a $25

co-payment

Inpatient 50%

Outpatient 50%

Deductible **

$725/person $1,450/family

$1,225/person $2,450/family

Co-insurance maximum

$3,100/person

$6,200/ family

$6,200/person

$12,400/ family

Life time maximum

none

* Maximum Non-Network Reimbursement Program (MNRP) as determined by United HealthCare

 ** Deductible applies to all network and non-network services except where noted. 

Employee Bi-Weekly Cost (Effective January 1, 2017)

Employee Only

$77.81/bi-weekly

Employee & Child(ren)

$135.32//bi-weekly

Employee & Spouse

$163.72/bi-weekly

Employee, Spouse & Child(ren)

$242.70/bi-weekly

 

Primary Care Physicians includes Family Practice, General Practice, Internal Medicine, Pediatricians, and OBGYNs.

 

Copyright © 2017 ABX Air, Inc. All Rights Reserved.
Please see ABX Air, Inc.’s terms and conditions for use of this web site.

Revised: March 17, 2017.